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Should you give birth privately?

A few people have been researching their options over the last few years about giving birth in Australia, and have asked me what I think about having private health insurance or giving birth in a private hospital.

Background: maybe you shouldn’t ask me! I’m not a health professional, I’m a mother of one, and he was born in a public hospital, in which I was a public patient.

And now, crucial fact about private hospital cover: it pays much of your hospital stay fees and some of your doctor’s in-hospital fees. It does not pay for private consultations with a doctor in an outpatient/private room setting.

You know what obstetricians charge a lot for? The “pregnancy management” fee, to cover your outpatient care in pregnancy. If I recall correctly, the Medicare rebate for this is on the order of $400 to $500. In Sydney, private obstetricians may charge upwards of $4000 for this fee. Who covers the difference? You do. (OK, full disclosure, the Medicare Safety Net may help too, I don’t know the details except that MSN actually cut benefits specifically for obstetricians a few years ago because they’d all upped their fees to incorporate the MSN rebate. So, mostly you do!) Also, anaesthetists in the private hospitals usually end up with a decent gap fee, if you have an epidural or Caesearean.

So, private system birthing is expensive regardless of insurance.

Finally, tests like ultrasounds are usually Medicare plus out-of-pocket too.

Now, birth choices in Australia.

Homebirth. There are some very small number of hospitals in Australia that will allow their midwife staff to attend some homebirths. It’s very easy to get disqualified from such a program. I would be on several grounds (some more legit than the one I’m about to give you), including the simple fact that my son’s birthweight was over 4.0kg.

You might also birth with a privately practicing midwife, or, in theory, with a private midwife collaborating with an obstetrician as backup (there are very few such arrangements so far). Most, although not all, private midwives will also only work with pretty low-risk women (singleton pregnancies, head-down, no high blood pressure or diabetes, that sort of thing, about 80% of pregnancies get a low-risk classification IIRC).

Is private insurance useful? Some private health funds provide some limited cover for this, I believe, on the order of $1k to $2k of the midwife’s fee, which is around $5k last time I looked. In the collaboration setup Medicare contributes too, I think?

Birth centre These are midwife-only maternity units attached to public hospitals. (Sometimes at some physical distance, eg Ryde Hospital only has a birth centre, with transfers to Royal North Shore several suburbs away.) You need to be assessed as low risk and if that assessment changes (and this isn’t uncommon, eg, your baby is breech or you get diabetes or pre-eclampsia) you get summarily transferred to the doctors and your whole care team often is suddenly switched out from under you. (Also they usually don’t do epidurals, I think? So the transfer rate for pain relief is not insubstantial I believe.)

Is private insurance useful? No, this is publicly funded.

Public hospital, midwife’s clinic If you go to a public hospital, and are assessed as low risk, almost all of your pregnancy management will be by midwives. Often they “caseload” now, meaning you see the same one each time. Again, if you become high risk, swish, off to the doctors.

Is private insurance useful? No, this is publicly funded.

Public hospital, doctor’s clinic. If you aren’t low risk, this is you. (This was me.) Chronic health problems or pregnancy complications (like pre-eclampsia) put you here. For your appointments, or at least most of them, you see an OB registrar or staff specialist. On high rotation, often, that is, you won’t usually see the same one many times. If you have a vaginal birth it may still be midwife-only, or largely midwife managed.

Is private insurance useful? No, this is publicly funded.

Public hospital, private doctor’s patient. In this case, you choose your doctor, see them mostly in their own clinic, birth in a public hospital (with you or your private insurer paying for the facilities) with the doctor of your choice attending. This is subject to gap fees for the doctor.

Is private insurance useful? Yes, pays for your accommodation and some of the OB’s and anaethestist’s (if needed) gap.

Public hospital, private midwife’s patient. This depends on a midwife/obstetrician collaborative practice. As I said, rare, but there’s at least one that allows a public hospital birth (private admission) with the midwife of your choice: Melissa Maiman in Sydney.

Is private insurance useful? Yes, pays for your accommodation. Not sure what happens if an OB and/or anaethestist are needed.

Private hospital, private doctor’s patient. There’s no midwife-managed option. If you’re birthing in a private hospital, you need a doctor of your choice attending. Again, pre-birth consultations in their own clinic, and subject to gap fees.

It’s definitely worth noting that while your private doctor will be an obstretrician and can manage higher risk pregnancies, for really serious stuff like prematurity earlier than a certain point, pregnancies with more than 2 babies on board (I think) and similar, they will actually refer you into the public system!

Is private insurance useful? Yes, pays for your accommodation and some of the OB’s and anaethestist’s (if needed) gap.

Public hospital, high risk clinic. I don’t know much about this, I’m told it’s the next level up in risk, and it well might be my next pregnancy. Joy. This is where you end up with OBs with a high risk interest, maternal-fetal medicine specialists (OBs with a formal subspecialty in very high risk pregnancies), renal physicians, endocrinologists, etc. This often involves referral to a tertiary hospital. (Sometimes specialists can consult without you being in one of these, like, an endocrinologist might monitor diabetes or thyroid hormones with you in the regular doctor’s clinic or seeing a private OB.) Birth choices guides don’t talk about this option very much, because you don’t really have a choice at this point (except birthing unattended or with a very risk-tolerant private midwife).

Is private insurance useful? I’m not sure, to be honest. It probably depends on the risk profile of your actual birth, I guess? If your birth is able to be attended by a regular private OB, maybe they let you do this? But you can do this publicly too.

Further reading on birthing choices

My Birth has a lot of information on birth procedures and the outcomes of different birthing providers, from a low intervention advocacy standpoint. One thing of note which gets picked up a lot by low intervention advocates is that despite the private birthing system referring all their hardest cases back to public, and despite the public patient profile being poorer with less good preventative health care and so on, private hospitals have much higher intervention rates.

Conclusion

It really depends on where you want to birth and with who attending. If the idea of the same doctor doing your pregnancy management and attending your birth appeals, that’s tending towards private birthing and thus private health insurance. But it has high out of pocket costs on top of the insurance premiums. (Note also that private health insurance policies are expensive if you include obstetric coverage, and will always have a 12 month waiting period for it, so you must obtain it before pregnancy.)

I was reasonably happy as a doctor’s clinic patient for my first birth. If I was low-risk I’d probably likewise go public, ideally with a birth centre or caseload midwife pregnancy+birth.

I have an interesting, albeit US-centric, perspective on this. I gave birth twice. The first was with a private doctor at a private hospital in the fancy end of town. Because Claire was born on Christmas Day the doctor was on holiday anyway, so the attending was someone I’d never met before (she was lovely.) We paid out of pocket for a doula, and she was worth every cent, especially when she got me through the part where I was begging for an epidural. She also made several post-partum visits and was incredibly helpful with getting breastfeeding established.

It was a good experience but I had to fight for it. The OB put a lot of pressure on me to schedule an induction when I was 4 days post dates. Luckily my water broke before the induction was scheduled. Of the 29 women who gave birth at my hospital that night I am the only one who didn’t have an epidural. I told the anesthetist I was hoping to do without, and he laughed at me and said “I’ll see you in a little while.”

So for my second birth I went with a midwife attached to an OB practice. My midwife combined the roles the doula and the attending had played in the first birth. All my prenatal appointments were with her, and several of them were home visits. She was with me from when I arrived at the clinic in labour until Julia was born, and she visited us at home after the birth as well. The clinic was in the hospital, right next door to an excellent OR, so I knew that if everything went pear-shaped the baby would be delivered safely; in fact, that exact thing had happened to a friend of mine at the same hospital three weeks earlier.

Claire’s birth was a good experience but Julia’s birth was near-optimal. As a result, I’ve become a great advocate for midwife-attended births at hospitals. Ironically, the hospital changed hands after Julia’s birth, the fantastic program (put in place by another friend of mine) was dismantled and my epic, awesome midwife could not get insurance for a private practice. So that option no longer exists.

But based on my statistically insignificant sample of two, I would strongly encourage women to explore midwifery practices attached to hospitals. You get the continuity of care you want from a birth attendant combined with the surgical intervention you need in case anything goes wrong. All women should have such options and it’s a scandal that so few women do.

“I would strongly encourage women to explore midwifery practices attached to hospitals” should read “I would strongly encourage low risk women to explore midwifery practices attached to hospitals”. High risk women will just be disappointed: I haven’t heard of any midwifery+hospital structure anywhere in Australia and the US (except maybe Melissa Maiman’s setup?) who are authorised to say anything other than “and the doctor’s clinic/this OB I know is also very nice…” Among countries I’ve heard about there are some high risk medical midwifery practices in New Zealand, and it sounds like there may be some in the UK and Canada too. But not in Australia or the US. (You can have less medical midwives, but this also sucks if you want mainstream management of your risk factors.)

The midwives at the hospital where I birthed asserted that they could have done my routine care and had a doctor look over my chart for most of my pregnancy, but they weren’t allowed and I don’t meet the risk profile for birth centres: here they usually don’t even allow VBACs (which isn’t my situation, but VBACs are pretty low risk as not-low risk goes).

It’s true that birth centres here often give you continuity of care if you need to transfer during birth (eg for a Caesearean section), but sadly usually not if you need to transfer for, say, pre-eclampsia. In that case, because you can be safely left alone, you just get told to present to the doctors for care from then on and to the labour ward rather than the birth centre for birth (with ward, not centre, midwives). Care relationship severed.

People I know who have birthed in birth centres adore them. People who transferred out loathe them, because of the trauma of the broken promise of care provider continuity plus the trauma of transfer.

A caseloading midwifery model where high risk women also get access both to midwife continuity and to adequate medical attention is essential.

In Norway the private alternatives are very limited. There are a few (but a growing number) doulas, and a few midwives that offer home births. AFAIK no insurances cover them, since such insurances are tailored towards companies and usually guarantee treatment within few weeks and treatments to get you fast back to work. The government will cover about 300$ of an homebirth (i.e. they give this sum to anyone who gives birth outside a hospital/birth center, regardless of why they did this – planned or unplanned homebirth, ambulance, private car, in the supermarket, whatever), but the total bill will usually be around 1000-1300$. There are about 100-150 planned homebirths (of about 60.000 births/year). There are no private hospitals for births, and you can not pay for a private doctor to do your birth in a public hospital. Pregnancy management is usually done by GPs, midwives or a combination. It’s usually not the same midwife that will follow your birth – the midwives use to work parttime in a health clinic and parttime in maternity wards at hospitals, so they do births in addition to pregnancy management, and should you come to hospital while “your” midwife is there, they’ll of course try to assign her to you. For high risk pregnancies or if there is a need for extra checkups you’ll be referred to a hospital. Based on what I know about your medical history you’d probably receive frequent checkups alternating between your GP and midwife (combination, or just your GP), and then a few checkups by relevant specialists in hospital. I guess you can also go to a private ob/gyn for pregnancy checkups, but I think these will not be free as you won’t be referred to a private ob/gyn for this. Referrals to hospital ob/gyns are done on a purely medical basis, and as all other referred pregnancy care they will be free. The most common private pregnancy care people get is early ultrasound. About 70% or so do a 12 week scan, maybe half of them do this on some medical indication (including “I don’t know how far along I am”) and the other half pay about 200$ for the scan. The regular ultrasound is done in hospitals around week 17-19, and is free. About 99.5% or so do this (I have heard many people in other countries say they opt out from this scan because they don’t want to know the baby’s gender, but it’s by no means compulsory to reveal, and the technician don’t really look close enough at genitalia for a layman to recognize them – genitalias are not considered “vital organs” at that stage here). Births are usually given either in birth clinics or in hospitals. The birth clinics are run by midwives with a doctor (ob/gyn) available backoffice, and often with an anaesthetists avalable (so you can have an epidural). Some of them only have midwives and no doctors, in the cities these are located close to the university hospital, and offer a very low-medical setting. Usually these clinics will offer all pregnancy management as well. These are for low-risk births, more or less as you describe them. Another kind of these clinics are the very decentralized units scattered all over the country, having rather few births per year, but offering a local alternative for women giving birth in rural areas. Again, low-risk births, but by many regarded a slightly more risky alternative since these clinics are definitely not located next to the university clinic, but more like 400 km from the nearest one, with an ambulance plane or helicopter on call in the “area”. They still offer a popular alternative for the women living there, since it means giving birth in a place you can drive to, not one you have to fly to at least 2 weeks before due date. Births that are not low-risk usually happen at regular hospitals. The hospitals as such are run by doctors, but midwives attend all births (both vaginal and c-sections), and will be in charge of most births except the most high-risk and the c-sections. They will call an anaesthetists, ob-gyn or other specialists when needed. In my case a doctor were called to break the water (because the midwife felt some structures that could be blood vessels), but for the rest of the birth only the midwife was present. I had a medium risk birth, with a history of high blood pressure and obesity. This time I will receive antibiotics during birth, so there may be more doctors present (including a pedatrician), but the birth as such is still not regarded risky, and postpartum I’ll be kept at the maternity ward in stead of being transferred to the hospital hotel. High risk births will usually be at the university hospitals (4 of them in Norway) or in one of the bigger hospitals, it depends on what kind of risk there is. In case of severe hearth problems (mother or child) the birth will probably be in one of two hospitals, very premature births are also centralized. To use you as an example again, you’d probably give birth in either a university hospital or in one of the other big hospitals (again given that I don’t know all your medical history). But also these high risk births will be attended by a midwife, with a bunch of specialists present or available. If you at any time is transferred to a higher degree facility, you will usually change care staff, although some of them will usually stay with you at least during the transfer. I think I might have chosen to give birth in a birth clinic if I knew I had a low-risk pregnancy and birth. But given that I KNOW I am by now means low-risk – high blood pressure, obese, and this time an infection (that most probably isn’t active anymore, and the risk is next to nil when I am treated with antibiotics – so no need to worry :)) – this isn’t really an option I have mentally considered. Also the closest birth alternative is a university hospital about 9 minutes from here, and driving to the alternative would be at least 40 minutes out of the city, so I would be really eager to consider that. In other cities there are such clinics connected to the hospitals, and there they would be a more logical alternative, although still nothing I’d seriously consider due to my medium/medical risk status. Postpartum care is given in the maternity unit, or for women who are at low postpartum risk in hospital hotels (special maternity units) for the hospitals that have that. The risk status before birth doesn’t alone decide whether you can be transferred to the hotel after a vaginal birth (c-sections always stay in the maternity unit), they check you 6 hours after birth and decide then (my blood pressure was not an issue postpartum, for instance). But there are some conditions that make them keep you in the maternity ward, e.g. profylactic antibiotics during birth (and of course more serious medical conditions). Some maternity units have single rooms (my hospital only has that) so dads can also stay there, others have shared rooms with up to 4 women (and no dads and usually strict visiting hours). Usually the facilities only depend on the age of the hospital (buildings) – during the last 10 -15years or so they are build with single rooms (at least in maternity units), but older buildings have bigger rooms. There isn’t much professional fighting between doctors and midwives here, probably because both doctors and midwives have been part of the birthing institutions in Norway for about 100 years. There were quite a few midwife run birthing facilities (especially in rural areas) until the 60ies, but they were overseen by the district doctor, and while he was by no means an ob/gyn it meant that there was a cooperation between these two professions. Recently there was a hearing about homebirths in Norway, and how to manage them as safe as possible. Most of the organizations that replied to the hearing were positive – except the doctors’ association, which were quite negative to most of the report. They are also generally more negative towards the decentralized centres, but usually not to the birth clinics located next to the hospitals, although they want only the most low-risk women to give birth there. It’s quite obvious that they regard a non-doctor setting unsafe, but they don’t automatically want to attend all births themselves – just be close.